Targeted Temperature Management Enhancement program for Critical Care Nurses

United Christian Hospital

Post Registration Certificate Course in Intensive Care Nursing

Group members:

  1. Ip Ching Ha
  2. Lau Kim Ngai
  3. Lam Nim Chi
  4. Shum Tsz Yan
  5. Tsui Siu Ting Desmond


AHA guideline for Post Cardiac Arrest Care

Targeted Temperature Management was formerly known as

Therapeutic Hypothermia


  1. Define TTM
  2. Ensure a standard of care
  3. Understand inclusion and exclusion criteria for TTM
  4. Introduce methods of cooling
  5. Tackle complications during TTM
  6. Introduce the TTM Checklist
During cardiac arrest.... What happens?
  1. Stores of oxygen in brain lost in seconds
  2. Stores of glucose and ATP lost within 5 minutes
  3. Loss of transmembrane electrochemical gradients
  4. Failure of synaptic transmission and action-potential firing
  5. Release of glutamate and accumulation of intracellular calcium causing neuronal necrosis

(Holdon M, 2006)

Reperfusion injury

Why reperfusion will cause harm?

The ischaemic cascade

(Muengtaweepongsa, 2015)

Effects of Targeted Temperature Management
  1. Decrease in brain metabolism
  2. Decrease in oxygen demand
  3. Decrease in glutamate and dopamine release
  4. Decrease in ATP consumption
  5. Decrease reoxygenation thus decreasing lipid pre-oxidation and oxidative stress
  6. Decrease in calcium overload
  7. Suppress inflammation from cerebral ischaemia

All the above contribute to a reduction in reperfusion injury

(McCullough JN, et al., 1999)

(Safar P, et al., 2002)

(Jerome YY and Johanne A., 1996)

(Kvirivishvili G., 2002)

(Maier CM, et al., 2002)

(Calver, 2005)

Canadian Guideline for Post Cardiac Arrest Care
Australian Trial

An Australian trial done in 2002 showed that 49% of cooled patients had good neurological recovery vs 26% of those treated traditionally

(Bernard, et al., 2002)

European Trial

An European trial done also in 2002 showed that 55% of cooled patients had better neurological recovery vs 39% of those traditionally treated patients

(Holzer, et al., 2002)

Inclusion Criteria

Who to cool?

  1. Cardiac arrest with return of spontaneous circulation (ROSC)
  2. Ischaemic stroke
  3. Heat stroke
  4. Brain injury
  5. Uncontrolled hyperthermia
Exclusion Criteria

Who to stay warm?

  1. Bleeding tendency / severe bleeding
  2. Major surgeries within 14 days
  3. Systemic infection / sepsis
  4. Core body temperature already below 30 degrees
  5. Terminally ill / not beneficial from intensive care
  6. Pregnancy
  7. Responsive and following commands

(Holzer, 2002)

  1. Begins treatment early (possibly in AED, do not interrupt in Cardiac Cath Lab)
  2. Place central venous catheters and arterial lines, secure them
  3. Continuous temperature monitoring (skin and rectal temperature)
  4. Sedatives and analgesics (midazolam, propofol, fentanyl, morphine)
  5. Paralysing agents (rocuronium, cisatricurium)
  6. Instruments (cooling blankets, CritiCool machine)
  7. Obtain baseline vital signs and neurological status
  8. Explain to relatives the concepts and details of the TTM therapy
ALWAYS REMEMBER: Sedatives and analgesics BEFORE paralysing agents
Temperature Measurement
  1. Gold standard of temperature measurement is the temperature of blood in the pulmonary artery
  2. The lower esophageal temperature is the most rapid and accurate, noninvasive method of measurement of core temperature and is close to gold standard
  3. Rectal temperature also mimics core temperature but will have the chance of perforating the rectum or may have variable positions; thus it is not fully reliable
  4. In our ICU, we use rectal temperature as the reference to core temperature

(Saigal S, et al., 2015)

Induction Phase
  1. Cool down the patient to between 32 and 36 degrees in 4 to 6 hours without overcooling
  2. Provide continuous sedatives and analgesics
  3. Prevent shivering
  4. Give cold fluids, wet blankets, endovascular cooling devices
  5. Cold IV fluids should not be administered at jugular or subclavian central catheters as this may result in cardioplegia
  6. Provide external cooling with CritiCool +/- ice pads and wet sheets
  7. Continuous monitoring of temperature, other vital signs and neurological status
  8. Check skin integrity to prevent thermal injury (early signs include firmness and redness, then discoloured skin, then bluish, mottled skin colour)
  9. Withhold enteral feeding
Endovascular cooling device; detect blood temperature and deliver cold fluids
Body temperature regulation and homeostasis
Maintenance Phase
  1. Remove ice pads and wet sheets once the targeted temperature is reached if they are being used
  2. Keep the core body temperature within range (32 to 36 degrees)
  3. Preferably, achieve mean arterial pressure (MAP) 80-100 mmHg
  4. Practice standard neuroprotective strategies such as placing the head of the bed at 30 degrees
  5. Monitor for arrhythmia (most commonly bradycardia and J wave); discontinue TTM and start rewarming if life-threatening arrhythmias cannot be corrected
  6. Continuous monitoring of temperature, other vital signs and neurological status
  7. Check skin integrity every 2 to 4 hours. Cooling blankets may cause thermal injury
  8. Withhold enteral feeding
Atrial fibrillation and J-wave in hypothermia patients

Maintain at least 24 hours

from the time when we start cooling

Controlled Rewarming Phase
  1. Controlled rewarming starts at least 24 hours after initiation of cooling
  2. Turn CritiCool to Rewarm mode
  3. Rewarm slowly at a rate of 0.25-0.5 degrees every hour
  4. Monitor the patient for hypotension secondary to vasodilation caused by rewarming
  5. Maintain sedatives and analgesics (+/- paralysing agents) until core temperature reaches 36 degrees
  6. Continuous monitoring of temperature, other vital signs and neurological status
  7. The patient should be maintained at the controlled rewarming phase at 36 degrees for 48 hours to prevent fever; or until the physicians prescribed to terminate TTM therapy
Discontinue paralysing agents BEFORE sedatives and analgesics
Differences between 2010 and 2015. A step forward

In 2010

  1. TTM first
  2. Targeted temperature 32 to 34 degrees
  3. Only for patients in coma with ROSC after VF / VT
  4. Maintain patients in the targeted temperature for 12 to 24 hours

In 2015, they newly suggest

  1. Coronary reperfusion and intervention first
  2. Targeted temperature 32 to 36 degrees
  3. For all patients in coma with ROSC after cardiac arrest
  4. Maintain patients in the targeted temperature for AT LEAST 24 hours
  5. Prevent fever by using TTM

(Nielson N, et al., 2013)

A journal comparing patients survival rate under two temperatures
No survival benefits for a lower temperature

There are no survival benefits for patients receiving TTM at a lower temperature.

Yet a lower temperature causes more complications and side effects.

(Neilsen N., et al., 2013)

Therefore, balancing the risks and benefits, 36 degrees is the optimal temperature for TTM.

Nursing Care during TTM
  1. Unstable haemodynamics and arrhythmias
  2. Electrolytes imbalance
  3. Coagulopathy
  4. Shivering, which will generate heat and affect therapeutic effect
  5. Skin integrity
TTM Checklist

Distributed to you all on hand; Refer to the screen

Gather the materials we need to initiate TTM.

A summary of what items we need. We will explain one by one.

Preparation of the CritiCool

  1. Pour tap water into the CritiCool till the water level reaches the water-level indicator
  2. Turn on the mains switch and allow it for self-test
  3. Let the CritiCool run for 20 to 30 minutes to cool down the water before connection of sensors and water hose, if situation allows
The water level indicator is in red

Preparation of the patient

  1. Take blood for baseline laboratory results (ABG, CBC, APTT, electrolytes, etc), ECG, vital signs and temperature (both surface and core temperatures)
  2. Prepare IV sedatives and paralytic agents (midazolam, morphine, fentanyl, propofol, rocuronium, atracurium) as prescribed
  3. Undress the patient and place the CureWrap underneath the patient
  4. Connect the disposal rectal probe and skin probe to the machine
  5. Place the rectal probe into the patient's rectum and the skin probe to his forehead
  6. Connect the water tubings on the CureWrap to the CritiCool. Open all clamps after connection
Skin probe to SURFACE; Rectal probe to CORE


Wrap the patient


1. Choose "COOLING" mode
2. Set "SET POINT" temperature to 32-36 degrees as prescribed
3. Choose "OPERATION"


  1. Targeted temperature should be reached in 4 to 6 hours
  2. If core temperature does not drop within the first 2 hours, consider other additional cooling methods like ice pads, cold IV fluids infusion (cold IV fluids should be administered via peripheral IV sites but not jugular or subclavian central catheters)
  3. Document vital signs and both CORE and SURFACE temperatures Q1H in the Therapeutic Hypothermia Chart in CIS


  1. Check the screen on the CritiCool to see that the CORE temperature is approaching the target
  2. Check Q1H that it is operating in "COOLING" mode
  3. Observe patient closely for any complications
  4. Vital signs, temperature Q1H


  1. Check skin for thermal injury
  2. Watch out for shivering; if patient shivers, can provide Bair Hugger, and administer IV sedatives and paralytic agents
  3. Watch out for bradycardia and arrhythmias (chance for the presence of J wave in ECG)
  4. Watch out for electrolytes imbalance (hypokalaemia)

Controlled Rewarming

2. Confirm the core probe is in the rectum and press "Operate"
3. Rewarm at the rate of 0.25 degrees per hour to a target temperature of 36-37 degrees as prescribed


  1. Monitor vital signs and temperatures hourly during controlled rewarming phase until the prescribed target temperature is reached
  2. Monitor temperatures Q1H for 24 hours afterwards during normothermia
  3. Wean off paralytic agents as prescribed when core temperature reaches 36 degrees (wean off paralytic agents BEFORE sedatives)


1. Add 1 AQUATABS to the water tank and choose “Standby” mode for 60 minutes to disinfect
2. Clamp all tubings and disconnect from the CritiCool. Discard the CureWarp as it is for single-patient use
3. Plug in the connector to the water tubing of the CritiCool after 60 minutes of disinfection
4. Then choose "EMPTY" mode with the CritiCool connecting to a mains switch near a water basin to drain the water tank


If the patient needs to go for CT or MRI investigations

1. Choose "STAND-BY" mode

2. Then allow water to drain back into the machine for at least 2 minutes

3. Clamp all tubings and disconnect them from the CritiCool before transportation

4. No need to remove the CureWrap from the patient as it is compatible with CT and MRI investigations. Even for PCI, TTM can still continue

If patient develops cardiac arrest

Unwrap the patient and start CPR or perform defibrillation if necessary

Appendix on

  1. Physiologic effects of TTM on different organs and systems, &
  2. Pharmacokinetics in sedatives, analgesics and paralysing agents

are also distributed to you all.

Thank you.

Created By
Desmond Tsui


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